Dr. Russell Postier, a surgeon from University Hospital in Oklahoma City (and currently Acting Chairman of the Department of Surgery at the University of Oklahoma Health Sciences Center), was the featured speaker at our Oct 20 meeting in Stillwater. Dr. Postier, who had addressed our chapter once before (March 1994), explained that he has spent much of his career devising ways to avoid creating ostomies. He is the leading expert in Oklahoma on the Ileoanal Reservoir (pelvic pouch) operation for Ulcerative Colitis and Familial Polyposis. He is also working on surgical alternatives for rectal and pancreatic cancer.
Dr. Postier has done about 175 Ileoanal operations ("J-Pouch" version) since returning to his native Oklahoma in 1981. Before doing any of these operations on people, he experimented by performing 60 operations on dogs. (Previously, he had been introduced to the J-Pouch procedure while a resident at Johns Hopkins.) In the ileoanal operation, the entire colon and most of the rectum are removed, except for a small portion of the rectum including the anal sphincters. The distal small intestine (ileum) is then fashioned into an internal pouch for storage of stool, and connected to the anus, allowing normal bowel movements.
One key aspect: Although a small portion of the rectum is retained, its mucous lining is completely removed. This makes the procedure suitable for Ulcerative Colitis and Familial Polyposis, which are diseases of the colonic mucous lining, but not for Crohn's Disease, which involves the entire thickness of the bowel wall. Therefore, extra effort is made before surgery to verify that patients diagnosed with Ulcerative Colitis truly have that disease, not Crohn's Disease.
Dr. Postier usually does the ileoanal operation in two stages. Most of the work is done in the first operation, where the colon is removed and internal pouch constructed. The patient then has a temporary ileostomy for three months until the 2nd operation when everything is hooked up in final form and the temporary ileostomy removed. This allows the newly-built internal pouch to heal before it must actively pass stool. It also gives the patient experience of a conventional ileostomy; then, after the internal pouch is made functional, the patient can verify whether he/she is actually doing better than with standard ileostomy.
Dr. Postier noted that patients with this operation can engage in virtually any activities; for example, one of his ileoanal patients is a rodeo cowboy!
The most frequent complication of ileoanal surgery is "Pouchitis"--inflammation of the ileal pouch--which occurs in about 40% of cases. It can usually be treated with antibiotics, but in about 10-15 percent of these cases it becomes uncontrollable, so the pouch must be removed and the patient returned to standard ileostomy. (This is the most common cause for failure of the ileoanal procedure.) The origin of pouchitis was originally thought to be bacterial, but it now appears to be a continuation of ulcerative colitis--attacking the ileal pouch which, over time, becomes more and more colonic. Pouchitis is generally seen only in patients who have an ileoanal for Ulcerative Colitis, not Familial Polyposis.
In spite of its complications, the ileoanal procedure appears to be an effective solution--avoiding an ostomy and preserving reasonably normal bowel function--for about 90% of patients with ulcerative colitis, and has been found successful for up to 10-15 years. (It hasn't been around long enough to provide longer-term data.)
On the subject of Rectal Cancer, Dr. Postier noted that simple excision of the tumor--without creating a colostomy--can now be done for tumors located much closer to the anus than was possible previously. Also, combinations of chemotherapy and radiation have been found so effective that surgery can be avoided entirely in some cases.